Winter sports are winding down, but spring is just around the corner. Parents and athletes … Read More
Winter sports are winding down, but spring is just around the corner. Parents and athletes … Read More
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© 2016 New Hampshire Orthopaedic Center
by: Kathleen A. Hogan, MD
People who are obese (body mass index -BMI >30) have an almost seven times increase in the incidence of knee arthritis compared to those with a normal body mass index (BMI 18.5-25). Weight loss has been shown to reduce the pain associated with knee arthritis and improve function. However, many of my patients with severe knee or hip arthritis tell me that they are unable to lose weight because they cannot exercise due to their arthritis pain. How can you lose weight when you cannot exercise?
This article is meant to give you some suggestions and ideas on how to lose weight when your joints hurt too much to exercise. You should talk with your medical doctor before starting a weight loss program, and about specific dietary or physical limitations you may have.
My first suggestion is to keep a food diary. There are many free apps that you can download to your phone or computer which determine the caloric content of what you eat. For some people, just keeping track of calories can prevent over eating. Some patients tell me they do not eat very much but still gain weight.
Sometimes it is not how much you are eating but what you are eating. For example, 200 calories can be a plate overflowing with broccoli or carrots, half a hamburger, or half a candy bar. Which is going to fill you up the most? Unfortunately the candy bar tastes the best! Keep in mind that 200 extra calories take approximately an hour of walking to burn off!
Many restaurants now list calories which can help you make healthier choices. The cafeteria at Catholic Medical Center lists “better alternatives” to high calorie foods. For example, who would have guessed that Baked Potato chips have less calories and fat (130 cal, 2g fat) then French Fries (300 cal, 15 g fat)? A bagel with cream cheese has over 400 calories compared to only 170 calories in a slice of french toast. Small changes in food choices can sometimes make a large difference in the number of calories consumed throughout the day.
Being active throughout the day is also important. This increases the number of calories you burn. If you are very sedentary, you will need to consume considerably less calories each day to avoid gaining weight compared to someone who is more active.
Many patients with arthritis complain that their joints feel stiff when they get up from sitting. Your joints are made to move. Movement lubricates all joints, even those with arthritis. Just because your knees hurt too much to run on the treadmill does not mean that you cannot exercise.
Swimming, water aerobics, biking, and the elliptical trainer all put less impact on your joints then walking. Strength training builds muscle and burns calories. It also builds bone density. The stronger your muscles are, the better they support your joints which reduces pain from arthritis. If you have never lifted weights before, you may want to start off by working with a sports trainer or physical therapist to learn how to do it correctly.
Barre, pilates, and yoga classes can also improve your flexibility, strength, and balance in addition to burning calories. Some gyms and senior centers offer classes specifically designed for people who have arthritis. Exercising with other people can help you stay motivated. Even thirty minutes a day of exercise can have a positive effect.
Do not give up. Just because you had a cupcake and sat on the couch tonight watching television does not mean you cannot exercise or lose weight. Try not to be too hard on yourself and set realistic goals so that you will achieve them. Arthritis may make weight loss more challenging, but nothing is impossible. The first step is always the most difficult.
by: Kathleen A. Hogan, MD
As a specialist in joint replacement, I am frequently asked “How will I know when it is time to have my hip or knee replaced?” As we age, most people experience intermittent pain in their joints, usually worse with activity. Sometimes this pain is due to arthritis, but there are many other causes of joint pain. A few of these causes include muscle pain, stress fractures, tendonitis, fibromyalgia, Lyme disease, and inflammatory conditions. Arthritis is caused by damage to the cartilage of a joint. Pain from arthritis is the result of the inflammation this cartilage damage generates. Arthritic pain is often intermittent. If you have arthritis it is likely that you will have good and bad days. You may feel worse with changes in the weather. X-rays may show loss of cartilage and development of bony deformities.
Not all patients with hip and knee arthritis will need joint replacement surgery. Some patients have x-rays which show they have terrible arthritis and yet they continue to be active. Symptoms of pain and swelling can often be treated with anti-inflammatory medications and corticosteroid injections. Improving muscle strength can help reduce stress on the joint. Canes and walkers can be used to decrease the force of body weight on the joint. Weight loss can be especially beneficial as you place forces of up to 5 times your body weight across your knee joint during stair climbing.
Most of my patients with arthritis want me to tell them if they are ready for a joint replacement. My response is that you will tell me when you are ready for surgery. Only you know if the discomfort and pain that you experience is bad enough to have a major surgery. Does your knee or hip hurt you every day? Does your arthritis pain keep you from doing things that you enjoy? Keep in mind that joint replacement does not give you back the knee or hip you had when you were 20 years old. This is an artificial joint made of metal and plastic. It will feel better than your arthritic joint but different than a normal one! The majority of people who have their hip or knee replaced are happy with the results and feel that they “have been given their life back”.
Joint replacement surgery is not without risks. Although complications are rare, they can and do occur. When your arthritis pain can no longer be improved with other treatments, the benefits of surgery – relief of pain, improvement in mobility, increased function – far outweigh the risks. No one should feel they were “talked into” having joint replacement surgery by their surgeon or even by a family member. Deciding to go forward with joint replacement surgery is a decision which will have a major impact on the rest of your life, and it needs to be your decision.
by: Kathleen A Hogan, MD
Over 30% of Americans over the age of 60 are affected by the symptoms of knee arthritis, such as pain, stiffness, swelling, and activity limitations. Initial treatments for knee arthritis include activity modification, weight loss, physical therapy, bracing, anti-inflammatory medications, and injections with steroids or hyaluronic acid (also called a gel or visco because of its consistency).
Corticosteroid injections have been used since the 1950’s to treat painful, inflamed, arthritic joints. However, they can cause temporary elevation of blood sugar in diabetics and may only give 3 months of pain relief. Even if effective in the past, repeated steroid injections may no longer provide relief. There is concern that too many steroid injections may damage normal cartilage, especially in patients with less severe arthritis. Steroid injections which are given within 3 months of a joint replacement surgery may even increase the risk of infection slightly.
Hyaluronan is a complex molecule found in normal joint fluid which acts as a lubricant and a shock absorber. Injections of a joint with hyaluronic acid may improve the protective effects of normal joint fluid and also reduce inflammation. First approved by the FDA in 1997, there are now several different types of hyaluronic acid injections available, including Synvisc, Euflexxa, Orthovisc, and Gel One. This type of injection is also known as viscosupplementation. Most require an average of 3 injections, one week apart, although some can be given as a single injection.
If your physician recommends viscosupplementation for knee arthritis, it usually must be approved by your insurance carrier before it can be given. You will return to the office for the injections. The skin will be cleaned with an antiseptic such as betadine, and the skin numbed with lidocaine or a cold spray. Some physicians use ultrasound to ensure the injection is accurately placed within the joint. Excessive fluid in the knee may be aspirated and removed at the same time as the injection, which can also provide substantial pain relief.
After the injection, it is typically recommended that patients avoid excessive activity for 2 to 3 days. This helps to minimizes discomfort associated with the injection. Bleeding within the joint after an injection can occur in patients on aspirin, Coumadin, or other anticoagulants. It typically takes a few weeks after completing the injections to obtain maximum relief of symptoms. Pain relief should last 6 to 12 months. These injections can be repeated every 6 months.
Viscosupplementation does not always give complete relief of pain. Studies have provided conflicting evidence on its effectiveness. A torn meniscus may be aggravating the knee joint and causing continued pain. Once arthritis becomes severe, these injections may no longer be effective. Or pain which is felt in the knee may actually be caused by arthritis elsewhere, such as the hip or spine. Not everyone is a candidate for viscosupplementation but for some patients they can provide significant relief of the pain from knee arthritis. If you are one of the million of Americans suffering from knee arthritis, there are often many treatments which can help to reduce knee pain and may help some people avoid or put off joint replacement surgery.
by: Kathleen A. Hogan, MD
In July, I will be traveling to Kinshasa, the capital of The Democratic Republic of Congo with WOGO – Women Orthopedist Global Outreach – on a medical mission to perform knee replacements at the Biamba Marie Mutombo Hospital. There will be over 50 people who travel with us – including nurses, scrub techs, and physical therapists. A tremendous amount of planning goes into these mission trips in order for them to be successful.
A year before the trip, last July, the pre-team consisting of 2 surgeons and 3 team leaders traveled to Kinshasa. They met with the hospital surgical staff and started the process of building a relationship with the orthopedic surgeons. They discussed how we will select our patients, the availability of OR rooms, sterilization equipment and supplies. We also need to determine where the team will stay and eat during their stay here, and identify transportation needs. During every trip we plan educational talks for the health care professionals in the hospital and community service projects in addition to our surgeries, and these also need to be planned ahead of time. This was a quick trip, less than a week, and so much was accomplished.
The Biamba Marie Mutombo Hospital in Kinshasa is the most modern hospital in DRC. Built in 2007, it has 150 beds, an ER, and ICU. The hospital has a partnership with local medical schools. The hospital was built by the Dikembe Mutombo Foundation (dmf.org). Dikembe Mutombo, an NBA legend and all star, has devoted his post basketball life to improving the lives of people in his homeland. He is actively involved in the hospital and will be traveling together with us on our trip in July.
We are shipping all of our supplies to Kinshasa by cargo ship. Although cheaper than shipping by air, this requires that the shipping occur 4-6 months before we arrive. Zimmer -Biomet donates the knee replacement implants. But we also need to bring everything with us that we will need to care for our patients. Surgical drapes, gloves,sutures, and dressings. Betadine to clean the skin. Teds stockings to prevent swelling after surgery. Antibiotics. Crutches and walkers. Bedpans. These are supplies that we take for granted in our hospitals but are not always available in third world countries. Many of these supplies are donated by the hospitals that the surgeons and members of the team work at. Locally, Catholic Medical Center, St. Josephs Hospital, and Bedford Ambulatory Surgical Center have been extremely generous in donating many boxes of supplies for our trip.
Next month, 2 surgeons, a medical doctor, and 3 nurses will travel back to Kinshasa to evaluate patients prior to surgery. In prior mission trips, this evaluation has taken place on the first day of our trip. Patients are seen and evaluated for their suitability for surgery. We will know ahead of time how many patients we will be treating. Patients will know that unless their medical condition has changed drastically, they will be having their knee replaced in July. We expect that some patients will travel quite a distance to the hospital so this will keep them from being disappointed.
These trips are expensive. We are still in the process of raising funds for our trip. A special thanks to the NH Women’s Weekend Tennis League who chose WOGO as their charity to support during the recent Diva Doubles Tennis Tournament! All of the members of the WOGO team are excited about our upcoming trip and focused on making sure the planning and organization is in place to make it successful.
by Kathleen A. Hogan, M.D.
One of the most common complaints after knee or hip replacement is difficulty sleeping. By six weeks after surgery, most people are having less pain in their new joint and increasing their activity. But they often lay awake at night, unable to sleep. Why does this happen and what can be done about it?
Many people have difficulty sleeping in the hospital immediately after surgery. This has many causes, including the stress response to surgery, cytokine release from soft tissue injury, the pain, medications, and the hospital environment. REM sleep (associated with dreaming) is diminished for the first few days after surgery.
Surprisingly, there are no published studies on the frequency of sleep disturbance several weeks or months following joint replacement surgery. However, in one study of patients with broken bones, 41% of patients with shoulder fractures and 36% of patients with knee fractures had difficulty sleeping 3 months after the injury. Even a year later, 20% of patients still reported insomnia.
Insomnia after joint replacement surgery can have many causes. Pain and discomfort are common complaints. Narcotic pain medicines can also disrupt sleep patterns, and decrease the time spent in REM sleep.
What can you do if you are still having difficulty sleeping several weeks after surgery? First of all, make sure you discuss this with your doctor, as she or he may have specific recommendations for you. Good sleep hygiene is important. Avoid caffeine and alcohol immediately before bedtime. Avoid napping during the day. Limit the use of electronic devices in the evening, including your phone. Create a quiet, peaceful atmosphere in your bedroom. Create a peaceful bedtime routine which allows you to relax and instead of dwelling on the discomfort you are having from your surgery. Consider using an eye mask, ear plugs, or a white noise machine. Meditation techniques can be helpful in promoting relaxation. Supporting your leg with pillows can improve comfort.
If you are unable to sleep after 30 minutes, do not lay in bed thinking about how you can not sleep. Get up, go to another room, and read quietly listen to relaxing music, or sit in a chair in a darkened room. Do not watch TV or check email! Using electronic devices will stimulate the brain and cause you to become more awake. Make sure you are getting exposed to some natural light during the day and keep your sleep environment dark as this helps to maintain normal sleep cycles.
What about medications? If you just had surgery, taking your pain medication 30 minutes prior to bedtime is recommended. However, keep in mind that your body may become accustomed to this routine and you may develop insomnia when weaning off these medications. Medications which help with sleep are often habit forming and should be avoided. Some people find Benadryl or melatonin to be helpful, but you should discuss this with your doctor.
Depression is not uncommon after surgery. Sometimes the recovery period can be quite overwhelming. Symptoms can include persistent feelings of sadness and hopelessness. Difficulty sleeping, loss of energy, anxiety, and irritability can also be symptoms of depression.
If you are having problems sleeping after surgery, make sure you talk to your surgeon about it. However, it can take quite some time for the sleep issues after surgery to resolve. It can be a very frustrating aspect of the post operative course after joint replacement surgery. It can take several months for your body to fully recover from the effects of surgery.